Comment for CMS

RE: CMS-5517-FC; Medicare Program: Merit-Based Incentive Payment System and Alternative Payment Model Incentive under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models

December 19, 2016

Submitted via

Mr. Andy Slavitt
Acting Administrator
Centers for Medicare & Medicaid Services
U.S. Department of Health and Human Services
7500 Security Boulevard
Baltimore, MD 21244

Dear Acting Administrator Slavitt:

Thank you for the opportunity to provide additional input on the concept of virtual groups as included in the final rule for the Medicare Access and CHIP Reauthorization Act (MACRA). We believe that small and solo practices lie at the crux of the shift toward high-quality, value-based care. Consequently, we appreciate the agency’s leadership on this important topic, as we believe that virtual groups can and should be a powerful tool to not only create administrative efficiencies for participating providers, but also to clinically benefit patients and to encourage collaboration that improves the quality of their health care.

Elation Health is dedicated to strengthening the patient-physician relationship by developing an electronic health record that enables independent physicians to provide patient-centered and collaborative longitudinal care. Our Care Network, which includes the Collaborative Health Record and the Elation Provider Network, gives providers the ability to promote high-quality care through a collaborative, team-based model, and to take action based on the most up-to-date clinical information to avoid the fragmented and unreliable experience of coordinating care on other IT systems.

Our Collaborative Health Record, for example, allows all providers caring for a mutual patient to easily share patient data and coordinate care in real time (with patient consent). Our Provider Network allows providers to easily find and contact physicians that they have shared patients with before, automatically surfacing the lists of providers with whom a patient has had actual clinical experiences.

In general, the providers we work with are independent providers that work in small practices, often in rural areas. Our goal is to ensure that these providers have access to health IT tools that allow them to spend time with and improve care for their patients – not wasting valuable time entering data that can’t ever be used or found into a system that isn’t user-friendly and can’t be used to collaborate with other clinicians who share the responsibility for patient care. Currently, our network reaches 240,000 providers, and our footprint is growing every day.

Given the profile of our client base, we are particularly interested in the impact that the Quality Payment Program will have on small, independent providers. As has been widely reported and discussed, the proposed rule estimated that 87% of eligible clinicians in solo practices and almost 70% percent of eligible clinicians in practices of 2-9 providers would likely receive a negative payment adjustment in 2019. In contrast, CMS estimated that only about 18 percent of eligible clinicians in groups of 100+ eligible clinicians would receive a negative payment adjustment in the same time frame.

While we appreciate that CMS significantly revised its initial estimates in the final rule, Elation Health believes that the primary solution to helping providers succeed under the Quality Payment Program should be to expeditiously ensure that clinicians in small practices have the tools needed to succeed under the new payment paradigm. Virtual groups are one such tool, and we urge CMS to implement the virtual group reporting option as soon as possible. This provision benefits the independent clinicians attempting to navigate the complexities of reimbursement reform by allowing providers to collaborate and pool resources without sacrificing their independence. Unlike larger practices, which can afford dedicated resources and infrastructure, small practices face a disproportionate burden under MIPS, making virtual groups a much needed, far-reaching attempt at lessening this burden.

Given the complexities of implementing virtual groups, we believe that it would be helpful for CMS to adopt a set of guiding principles to inform its work. The following principles should serve as guideposts for CMS to follow, and should inform the development of this new program:

• Virtual group participation should improve the quality of care received by patients of the participating providers by facilitating care coordination and improvement activities.

• Participating providers should be able to demonstrate clinical “connection” with other providers in the group.

• An alternative organizing principle to clinical connection should be a demonstrated benefit amongst the providers from sharing knowledge and best practices to positively impact patient care.

• Providers should be encouraged to organize in multi-specialty virtual groups. This will result in the “connection” and collaboration mentioned above, and will reflect that high quality care is delivered by multidisciplinary care teams.

• Virtual group participation should be limited to independent providers in small practices, and should be confirmed as practices with fewer than 10 providers.

• Virtual groups should not be required to adopt a single EHR system. They should, however, have other technology tools in common to accurately aggregate and calculate clinical and quality improvement data.

Our specific comments on many of the questions posed by CMS in the final rule are below. We have focused on topics and issues that we believe will be most impactful for independent providers — a group of clinicians that is key to the success of value-based care.

Standards for Virtual Groups

In the final rule, CMS noted that commenters on the proposed rule suggested an array of potential minimum standards for virtual groups, including requirements that providers have a mutual interest in quality improvement, care for similar populations, and/or are responsible for the impact of their decisions on the whole group. CMS is thus seeking comment on a number of topics, including the advantages and disadvantages of establishing minimum standards; the types of standards that would be established for members of a virtual group; and the advantages and disadvantages of forming a virtual group pilot in preparation for the development and implementation of virtual groups.

Recommended Standards. We believe that any standards for virtual groups should be patient-centered. They should not be arbitrary or administrative in nature, but should instead be aimed at ensuring that patients benefit from the creation of a virtual group. Data should be mobile between providers in a group, with important clinical information easily shared between providers. Elation’s architecture supports this, reinforcing the notion that patients should be placed at the center of care.  Our Collaborative Health Record architects Care Teams around dynamic patient records to improve care outcomes.

Pilot Considerations. We do not believe that it is necessary for CMS to form a virtual group pilot in advance of full deployment of the program. Instead, we support the limit of virtual groups to practices with 9 or fewer clinicians.  We believe that this segmentation will mean that  small practices will be exempt from reporting as a result of the low-volume threshold, the right practices will be targeted under the policy, and that moving quickly to provide these practices with the tools needed to succeed under these reforms should be the priority.

Technical and Operational Elements/Data Analytics/Metrics

In the final rule, CMS noted that several commenters recommended that CMS expand virtual groups to promote the adoption of activities that enhance care coordination and improve quality outcomes that are often out of reach for small practices due to limited resources; encourage virtual groups to establish shared clinical guidelines, promote clinician responsibility; and have the ability to track, analyze, and report performance results; and promote information-sharing and collaboration among its clinicians.

In response to these comments, CMS requested additional input on: the types of requirements that would be established for virtual groups to promote and enhance the coordination of care and improve the quality of care and health outcomes. The following proposals enumerate the technical and operational elements we believe CMS should incorporate into its framework for virtual groups.

Metrics to Demonstrate Connectivity. High quality patient care is delivered collaboratively, by groups of physicians, care coordinators and other providers. With technology, these connections can be measured, and should form the basis for membership in a virtual group. We recommend that CMS offer a clear set of metrics that providers can leverage to demonstrate connectivity, and allow providers to have flexibility by requiring that they show one or more (rather than all) of these indicators of connectivity.  Some examples of best practices include streamlined communications (e.g., secure messaging, electronic referral letters), a common patient population, and mutual use of the same hospitals and labs across virtual groups.

Metrics to Measure Care Quality and Outcomes. Under the final rule, most clinicians participating in MIPS will be required to report on at least six quality measures. In addition, measures such as the rate of hospital readmissions and the Risk Adjustment Factor (RAF) score can be utilized to demonstrate the effectiveness of virtual groups and their impact on care quality and health outcomes.

Technological Infrastructure

In the final rule, CMS indicated that it wants to make sure that virtual group technology is meaningful and simple to use for clinicians. With those goals in mind, CMS is seeking comment on 1) the factors an individual clinician or small practice who is part of a virtual group would need to consider for their certified EHR technology to have interoperability with other certified EHR technology if part of a virtual groups; and 2) the advantages and disadvantages of having members of a virtual group use one form of certified EHR technology.

We believe CMS should allow providers to choose their preferred EHR system, but require a set of shared tools that could integrate with their chosen EHR to advance interoperability. We believe true interoperability does not rely on manually requesting and sharing patient data across the care team, slowing down patient care. Instead, true interoperability through virtual groups should enable providers to have on-demand access to key clinical data to provide patients more timely care. Elation Health’s products, for example, include a quality measurement dashboard, as well as a messaging and communications suite and Collaborative Health Record features for care teams.

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We are excited for the prospect of virtual groups, and we are prepared to support the independent clinicians and practices that are interested in joining these “care teams.”  With the first MACRA performance period beginning in just a few weeks, we encourage CMS to act quickly to support these providers by releasing additional detail regarding virtual groups.

Independent provider-led initiatives like virtual groups should be at the forefront of CMS’ strategy for implementing MACRA. Thus, it is exceptionally important for CMS to continue to listen to the independent physician community and keep their interests close to CMS’ plans for improving patient care.

Thank you again for the opportunity to provide feedback. We look forward to working with CMS as it works to operationalize virtual groups under MACRA. Please do not hesitate to contact me if we can be a resource to you or your team.


Kyna Fong
CEO & Co-founder, Elation Health